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Based on observation, review of hospital documents, staff and patient interviews, the hospital failed to ensure the hospital Based on observation, interview and document review the hospital failed to ensure that dietary services met the needs of all patient. Hospital census was 28.

Findings:

1. Based on observation, staff interview and review of facility documents, the hospital failed to ensure that a dietary services employee was competent to calibrate a food thermometer accurately. This deficient practice could result in exposure of patients to food borne illness as a result of improperly cooked food. To be safe, time and temperature safety foods, previously termed potentially hazardous foods, need to be cooked to safe minimum internal temperatures to destroy any harmful microorganisms. (cross refer A-0622)

2. Based on observation, review of clinical records, staff and patient interviews and review of hospital documents, the hospital failed to ensure the hospital failed to meet the nutritional needs of all admitted patients to the behavioral center. The hospital failed to ensure that the menu met the nutritional needs of its patients as evidenced by the fact that the nutrient analysis of the menu, showed calories was less than what was recommended for the reference patient. The nutrition screening criteria used to determine nutritional risk was not appropriate for patients with psychiatric diagnoses. In addition, the hospital failed to properly assess two of five sampled patients (Patients 2 and 3). Patients were provided medical nutrition therapy provided in the absence of an assessment including education by a non- registered dietitian, a dietary technician registered (DTR), and not the registered dietitian- nutritionist (RDN) as recommended by the Academy of Nutrition and Dietetics (AND) when treating obesity. Patients in the Adolescent Unit were not offered al the items that had been planned resulting in decreased intake. (Cross refer A-0629)

3. Based on observation, review of facility documents and staff interviews, the facility failed to ensure there was an effective system in the prevention of infections when it failed to follow correct procedures for hand washing, maintain sanitary environment for food storage, preparation and distribution. There were several deficient practices observed in the hospital ' s kitchen that could contribute to the growth of microorganisms capable of food borne illness due to improper washing and sanitizing of food service equipment and calibration of a food thermometer. (A-0749)

The cumulative effect of these systemic problems resulted in the inability of the hospitals ' food and nutrition services to direct and staff in such a manner to ensure that the nutritional needs of the patients ' were met in accordance with practitioners ' orders and acceptable standards of practice.



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Based on observation, staff interview and review of facility documents, the hospital failed to ensure that a dietary services employee was competent to calibrate a food thermometer accurately. This deficient practice could result in exposure of patients to food borne illness as a result of improperly cooked food. To be safe, time and temperature safety foods, previously termed potentially hazardous foods, need to be cooked to safe minimum internal temperatures to destroy any harmful microorganisms. Hospital census was 28.

Finding:

During lunch meal service on September7, 2016 at 11:37 am, the surveyor took food temperatures. A review of the temperatures taken by the surveyor was checked against the one taken by Cook 2. There was about a large discrepancy between the temperatures taken by the surveyor and those recorded by the cook. As a result, the cook was asked in an interview when the thermometer used was last calibrated. Cook 2 indicated the thermometer was last calibrated that morning. Cook 2 further indicated that the thermometer registered 0 degrees Fahrenheit (F).

Food thermometers are usually calibrated by two methods: ice point method, in which a well calibrated thermometer would read 32 +/- 2 degrees F or the boiling water method, which a calibrated thermometer would read 212 degrees F. Cook 2 was therefore asked to demonstrate how the thermometer was calibrated. Cook 2 put ice in a container and inserted the thermometer (no water added). In the ice point method, ice is mixed with water in a 50/50 water to ice ratio.

Cook 3 was also asked to demonstrate how to calibrate the thermometer. Using a training tool, Cook 3 was able to demonstrate correctly the 50/50 ice water solution. The thermometer read 36 degrees F. Although Cook 3 knew the thermometer was out of calibration, and was able to verbalize the tools needed to recalibrate she did not know how to do it. The tool that could be used to turn the thermometer dial to the 32 degree mark was there on the sleeve of the thermometer, Cook 3 did not recognize it.

Cook 2 stated that on observing Cook 3 add water to ice, Cook 2 remembered what had been discussed in training.

The food service Director (FSD) who was present during the observation, stated that both cooks had been trained on thermometer calibration but validation of competency and knowledge was not evaluated, as in repeat demonstration.

Review of training logs indicated that Cook 2 had last attended training on thermometer calibration on August 19, 2015. The facility document Titled " How to Calibrate Thermometer " describes the Ice point method. It directs to use " crushed ice and water "

Based on observation, review of clinical records, staff and patient interviews and review of hospital documents, the hospital failed to ensure the hospital failed to meet the nutritional needs of all admitted patients to the behavioral center. The hospital failed to ensure that the menu met the nutritional needs of its patients as evidenced by the fact that the nutrient analysis of the menu, showed calories was less than what was recommended for the reference patient. The nutrition screening criteria used to determine nutritional risk was not appropriate for patients with psychiatric diagnoses. In addition, the hospital failed to properly assess two of five sampled patients (Patients 2 and 3). The hospital provided had medical nutrition therapy provided in the absence of an assessment including by a non- registered dietitian, a dietary technician registered (DTR), not the registered dietitian- nutritionist (RDN) as recommended by the Academy of Nutrition and Dietetics (AND) when treating obesity. Patients in the Adolescent Unit were not offered al the items that had been planned resulting in decreased intake. The hospital census was 28.

Finding:

Menu
During interviews with Registered Dietitian (RD) 2 on September 8, 2016 starting at 9:00 am, RD 2 indicated the reference patient was a 30 year old male, 5 feet 10 inches tall, weighing 180 lbs. The recommended caloric needs of this reference patient based on the (RDA) Recommended Daily Allowance) was 2600 calories. A review of the nutrient analyses of the Regular and Diabetic menus (Week 1) revealed that the total calories provided per day for the diets was approximately 2000 calories. This value is about 400 calories less than was recommended for the reference patient. In the concurrent interview, RD 1 and RD 2 were not able to clearly explain how the hospital determined the reference patient and why the menu only provides 2000 calories.

This is of significance because the hospital does not routinely assess all its patients including those on therapeutic diets. For patients with higher caloric needs, the hospital is unable to proactively adjust the menus to meet their needs. Patients would need to ask for bigger servings to meet their needs thereby delaying care since a physician ' s order is needed to change diet orders. Two sampled patients (Patients 2 and 3) were observed to request more food, the diet order for patient 3included notation: " pt. may request a second tray " . A consult was ordered for Patient 2, seven days after admission, before additional food was provided and food preferences taken. Patient 3 ' s order read " send double portions of protein with trays, send 2x hamburgers with cheese no bread, green salad L & D (lunch and dinner).

Assessments
During several interviews with the registered dietitians (RD1 and RD 2) on September 7 and 8, 2016. The RD1 and RD 2 both indicated that patients in the hospital are not assessed if they do not meet the nutrition screening criteria conducted by nursing staff on admission. RD 2 indicated on September 7, 2016 at 3:35 pm that the nutrition screening was to identify risk of malnutrition and the screening was the same as in the main hospital, which is a separately licensed and certified acute care hospital. According to the AND ' s (Academy of Nutrition and Dietetics) Standard of Practice and Standard of Professional Performance in Behavioral Health Care, each RD " provides input into the development of appropriate screening parameters to ensure that the screening process asks the right questions " .

According to the information used to determine nutrition adequacy for the menu, the population served the hospital is a 30 year old male. A review of the hospital policy titled " PC - Nutrition Assessment and Reassessment " with last revision date of 11/14 indicated that patients will be assessed by the registered dietitian only if they meet one of the parameters identified on the screening tool. The screening risk factors or parameters were mostly geared to the elderly population found in most acute care hospitals. They include unintended weight loss, pressure ulcer, home tube feeding, and use of dentures. These risk factors in the hospital ' s nutrition screening tool are not appropriate for the younger patients with mental health issues with the hospital serves. They do not identify the risk factors which put this class of patients are nutritional risk. These factors include mental health diagnoses in the Axis I and II categories, overweight, diabetes, heart disease.

The Psychiatric Nutrition Therapy: A resource guide for Dietetics Professionals Practicing in Behavioral Health Care, a publication by the American Dietetic Association (now Academy of Nutrition and Dietetics), Practice Group is a guide to providing nutrition services to persons with mental health issues. The publication outlines nutrition risk factors for persons with mental health issues. The Nutrition Risk Assessment parameters identified include the following: Diagnoses in Axis I and II such as Schizo-affective disorders, (manic type), psychotic disorders, Alcohol and Substance abuse and Axis III diagnoses such as hypertension, Diabetes Mellitus, Heart Disease all classified as moderate risks. Also classified as moderate risks in weight status are BMI of 25 to 29 with co-morbidities and BMI of 30-39 and BMI less than 18.5. (Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women). Diagnoses classified as high risk include Depressive Disorders, Major Depression, Schizo-affective disorders (Bipolar or Depressed) Malnutrition, Dialysis, 3 or more abnormal lab values among others. The hospital screening did not include any of the mental health diagnoses in the Axis I and II as nutritional risks.

Not only did the hospital policy not identify the appropriate risk factors, when risk factors are identified, patients may not be assessed by the registered dietitian until three days of admission and reassessment completed until a week later or sooner if changes occur that affect nutrition care. Adult patients that do not meet the screening criteria are rescreened ten days after admission. The rationale behind the assessment, including consults requested by the physician and nurse practitioner, reassessment and rescreening timeframes of these patients was not clear since according to the chief nursing officer (CNO), the average length of patients is five days. The CNO and RD 1 acknowledged the time frames were based on RD availability and not on patient needs and community standards for nutrition care.

Clinical record review also revealed that the RDs do not typically provide nutrition education or medical nutrition therapy. This responsibility is delegated to the diet technician in the absence of a nutrition assessment. According to the AND ' s Standard of Practice and Standard of Professional Performance in Behavioral Health Care the RD is responsible for the " identifying and implementing appropriate, purposefully planned actions with the intent of changing a nutrition related behavior, risk factor .... Selects specific intervention strategies that are focused on the etiology of the problem and that are known to be effective " . Without an assessment identifying and implementing the appropriate intervention purposefully planned actions is not possible.

Patient 2 was admitted to the hospital on 9/2/2016 with both medical and psychiatric diagnoses including type 2 diabetes, hypertension, hypothyroidism, hyperlipidemia, suicidal ideations, anxiety and auditory hallucinations. Patient 2 ' s clinical records showed that Patient 2 was 74 inches tall and weighed 300 pounds (lbs.).The calculated BMI was 38.5. Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women. A person is considered to have obesity when BMI is 30 or greater.

Review of the nutrition screening tool showed Patient 2 did not trigger for any of the risk factors on the nutrition screening tool. This according to the registered dietitian (RD2) in an interview on September 8, 2016 at 10:20 am, would indicate that the patient would not be assessed by the registered dietitian but would rescreened by the diet technician, registered (DTR) 10 days later.

Review of clinical record showed that the nutrition department received an order for a nutrition consult. Review of nutrition notes showed that the consult was conducted by the DTR. According to documentation, the DTR provided diabetic diet education on 9/6/2016 in which h/o ' s (handouts) was given and reviewed. Subjects discussed included CHO (carbohydrate), portions, label reading, etc.

The following day, the nurse practitioner requested another nutritional consult because patient was " asking for larger portions of protein with his meals " . An RD (RD3) documented she received another consult which was documented as " consult for food preferences " . RD 3 further documented Patient 2 did not remember nutrition education he received the day before and will require ongoing education during this admission. RD 3 did not complete a nutritional assessment to determine the nutritional needs of this patient but honored his food preferences for Chicken times 2, entrée sized salad, fruit, milk and ice tea for most meals without determining the appropriateness of the extra food.

Review of the laboratory values indicated that Patient 2 had a Hemoglobin A1C of 11.6 %, (normal value is 4.8 to 5.6%) HGB A1C or glycated hemoglobin test is an important blood test that provides an average of a person ' s blood sugar control over a two to three month period. (webmd.com). There is a correlation between Hgb A1C and average blood sugar. A Hgb A1C of 11.6 correlates with average blood sugar of 336 mg/dl. (webmd.com) Blood sugars a day after admission confirmed the high blood sugar correlation. Patient 2 ' s blood sugar on 9/1/16 was 309 and on 9/3/16 was 260 (normal values 70 -110).

The Hgb A 1C level indicates poor compliance with blood sugar control. There was no documented evidence that causes of the non-compliance was evaluated and information used to provide the appropriate therapy. The education was provided in the absence of proper intervention. Patient2 ' s educational and nutritional needs were not assessed.

2. Patient 3 was an adolescent admitted to the hospital on 8/30/16 with psychiatric diagnoses. Patient 3 was screened for nutrition risk factors for high risk pediatrics criteria and did not trigger based on the parameters screened for. Patient 3 weighed 135 pounds and measured 5 feet tall. The calculated BMI was 25. BMI of 25 is considered overweight, a parameter AND considers as a risk.

The initial History and Physical conducted by the physician indicated " Overweight. Patient not receptive to counseling on healthy diet. " On 9/4/16, Patient 3 ' s physician ordered a consult for diet education. Review of clinical record did show any documentation that education was provided. No nutrition assessments were conducted. Documentation by RD 4 only included documentation of food preferences.

In an interview with RD 2 on September 8, 2016 at 10:20 am, RD 2 indicated she had spoken to RD 4 who indicated the consult order was incorrectly written and order was for food preferences and not patient education as was document in the request for consult. MD ordered a weight check on 9/4/16 implying the physician was evaluating the patient for weight changes.

In the position paper on " Interventions for the Treatment of Overweight and Obesity in Adults " the role of the registered dietitian was identified. It states " The nutrition care process which includes nutrition assessment ... represents the intrapersonal level focus. The recommendation (rating: strong and imperative) was that the RDN (Registered Dietitian Nutritionist) should assess data including food and nutrition-related history, anthropometric data, medical tests to individualize the weight management program for the adults " . Although the position indicated there was a role that included the DTR or NDTR (Nutrition and dietetic Technician, Registered, the responsibility for the assessment, development of strategies and intervention was placed on the RD. The AND ' s position paper titled " Interventions for the Prevention and treatment of Pediatric Overweight and Obesity " states " dietary assessment and intervention efforts for both obesity prevention and treatment should focus on food and eating patterns known to be associated with the risk of development of obesity .... It is important for RDs and DTRs to receive training in skills that prepare them for challenges presented by the child-obesity epidemic. "

Review of the personnel record for RD1, DTR 1 and DTR 2 did not show any specialized training in the treatment of adults, pediatric and adolescent overweight or obese individuals.
Meal Service
According to the youth dinner menu on September 7, 2016, the following items were to be served: Local greens with broccoli and croutons served with Italian dressing, Chicken breast, black bean burger with guacamole (Vegetarian entrée), roasted red potatoes, fresh Italian vegetables, fresh seasonal fruit, herbal tea, lemon wedge, non-fat milk and low fat milk.

During dinner service on September 7, 2016 at 5:35 pm on the Adolescent unit, there was a tray with containers of what was described by food service staff as, mixed fruit and green salad located on the counter at the nursing station. There was also a box containing individual juice boxes. As the patients walked past the nursing station, these patients were offered the hot entrees from a food cart across from the nursing station. Several of the patients walked past the mixed fruit, salad and juice at the nursing station and only received the hot entrée items. They were not directed to the other items as additional items being offered as part of the meal.

There were condiments such as dressing for the salad on the shelf above the food cart. Some of the patients who picked up the salad did not pick up the accompanying dressing. It was not clear whether these patients were aware of the location of the dressing as the salad was behind them on one side and the dressing was on the opposite side above, on the shelf of the foot cart. They were also not directed by the staff present to take the Italian dressing for their salad if they so desired.

One of the patients picked up one of the containers of the mixed fruit and asked what was in it as the contents in the container were not visible. Neither the nursing staff nor the dietary staff serving the hot items was able to clearly explain the contents of the container. Several of the patients asked if they could have the guacamole that had been portioned out, in a container on the food cart. Many of the patients were denied the guacamole and were told it was for the Black bean burger. One patient was directed to ask the nurse if she could have it. Three other patients were not directed to the nurse to determine if it was allowed on their diets. All these patients were on regular diets. At the end of service no patient was observed to select the black bean burger and the containers of the guacamole leftover were not consumed.

One random patient indicated " You don ' t have hot sauce, I don ' t want the vegetables " . This patient did not pick or offered the green salad as an alternative. Other patients requested the bun that was for the black bean burger. So many patients requested for it that additional bread buns were brought for the patients.

In addition, milk was not offered. When RD 1 was asked on September 7, 2016 at 6:00 pm if milk is offered since it was not observed in the serving area, RD 1 indicated that patients are served in the dining room. Observation in the dining room during that meal did not show any milk cartons, glasses of milk or any evidence that milk was offered to the patients.

It had been determined in previous interviews that the hospital did not routinely check food preferences. RD 1 who was present during the observation stated in an interview September 7, 2016 at 6:15 pm, that the hospital had hot sauce and there was no reason the patients could not have it.

On September 7, 2016, the hospital admitted new eight pediatric patients (ages 8-14). Review of the lunch youth menu indicated the following items was to be offered: Romaine Lettuce with choice of Ranch, Blue Cheese and balsamic vinaigrette, Roasted Chicken, Linguini with Marinara, Rice, roasted carrots, fresh fruit cup, ice tea, herbal tea, Lemon Wedge, Non-fat milk and Low fat milk.

On September 8, 2016 at 12:30 pm, observation and staff interview with nursing staff indicated that meal service had already begun but none of the seven were actively eating. A check of the meal cart showed that the non-select menu choice had been offered. It was the vegetarian, non-meat entrée: Linguini with Marinara, Roasted carrots, fresh fruit cup and low fat milk. Several of the trays had food that was untouched. It was difficult to determine to whom the food trays belonged because the identifying information had been removed. A review of the diet list for the pediatric unit did not indicate any of the children had physician orders or preference for the vegetarian diet.

Nursing staff 1 indicated that all of the children had requested for an alternate item but mostly pizza. Thirty minutes later when the food cart arrived, there were seven trays of pizza, 2 turkey sandwiches and two egg salad sandwiches. RD 2 and RD 3 who were present during the observation were interviewed about the choice to offer the vegetarian entrée as the non-select entrée for the children especially because the alternate items selected by all of the children were meat choices. RD 2 and RD 3 in the concurrent interview indicated the menu met the nutritional needs of the patients and that the nutrient analysis was based on all three meals and milk was calculated as part of the protein needs for the patients. Only one food tray had evidence of milk being offered.

In response to how the hospital determined what items to put on the menu for both the adolescent and pediatric patients, the FSD indicated that a survey had been conducted a year and half or two before. Review of the document showed that most of the comments were related to food temperature and taste not about choices.

The meal set-up, lack of staff communication and lack of evaluation of meal choices and failure to provide items such as hot sauce and milk resulted in several of the patients not receiving all items that was available on the menu, thereby limiting calories and not providing menu as planned by the dietitian.

During interview on September 7, 2016 at 9:30 am with Chief Nursing and Operations Manager (CNO), RD 1 and RD 2, it was revealed that patients on a special diets were not allowed to come to the dining room and cafeteria because these patients especially the diabetics became non-complaint with their diets when they observed other food choices and quantities that may not have been allowed on their diets. The RDs indicated that some of these occurrences were disruptive such that dietary staff was negatively affected. As such the decision was made to restrict all patients admitted with physician ' s orders for special diets including therapeutic and food allergy to the patient floor with food trays sent as was preselected by the patients.

RD 2 indicated in the con current interview, that they did not see the revision as infringing on the rights of the patients.

Based on observation, review of facility documents and staff interviews, the facility failed to ensure there was an effective system in the prevention of infections when it failed to follow correct procedures for hand washing, maintain sanitary environment for food storage, preparation and distribution. There were several deficient practices observed in the hospital ' s kitchen that could contribute to the growth of microorganisms capable of food borne illness due to improper washing and sanitizing of food service equipment and calibration of a food thermometer. The patient census was 28. (Cross refer A 622)

Finding:

On September 7, 2016 at 10:21 am, during hand washing, the water running from the faucet was cold to touch. Attached to the faucet was an eye wash station. The water was allowed to run for several minutes not including three food service workers who were observed washing their hands. The water temperature of the faucet in the hand washing sink was 76.8 degrees Fahrenheit (F). Observations of other sinks (vegetable and three - compartment) in the kitchen revealed the use of water heater boosters.

An interview was conducted on September 7, 2016 at 11:15 am with the Facilities Manager. He stated that the water at the hand washing sink was kept cold because of the eye wash station that had been attached.

RD 1 and the food service director stated that none of the inspectors including the county environmental inspectors had identified it as a concern. Review of the hospital policy titled " Personal Hygiene " dated 2/2016 under the subheading Hand Washing described the hand washing procedure including use of running water to rinse. It did not include the temperature of the water. A second hospital policy titled " Gloves and Hand washing " dated 6/15 indicated in the hand washing procedure to wet hands with warm water ... .....Then rinse with warm running water " .

According to the 2005 Food Code, the minimum hand washing water temperature of 100 degrees F. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands.

2. On September 7, 2016 at 10:35 am, observation of the food blender stored away on a counter as cleaned was done. There was a light brown colored dried on substance (food) splatter on the lid, the base of the food container (jar) including the cutting assembly, the rim of the food container, in between the rubber gaskets and locking ring. The food service director who was present during the observation stated that the food blender is cleaned after each use.

Review of the hospital policy titled " Sanitation Program " dated 2/2016, identified a sanitation schedule for the department. The schedule listed items that needed to be cleaned daily, weekends and after each use. The food blender (processor) was listed in the after each use category. The schedule did not specify how to clean. In an interview with the FSD on September 7, 2016 at 10:35 am, she stated that there was no written procedure on how the food blender should have been cleaned. Manufacturer ' s instructions state " Empty blender jar and carefully disassemble parts. Wash cutting assembly, gasket and locking ring in warm soapy water. Rinse and dry all parts thoroughly " .

3. During lunch observation on September 7, 2016 at 1:42 pm, the temperature of the egg salad that was in the salad bar was taken. The temperature was between 48.6 to 51 degrees F. Dietary staff 2 stated in an interview on September 7, 2016 at 1:44 pm, the temperature of egg salad was appropriate, (37 degrees F) when she placed the egg salad on the cold table (salad bar) at 9:30 am.

Review of the hospital document titled HACCP Critical Control Points Daily Temperature log confirmed the temperature and time. The FSD and Cook 2 both stated that they were not aware the egg salad had been placed in the salad bar that much in advance. The recommended temperature for holding cold foods is 40 degrees F and below according to the log. Other instructions on the log indicated product temperature must be recorded on the log every two hours during holding and serving. There were no other temperatures recorded for the egg salad. The egg salad had been held for approximately 4 hours when the temperature was taken. There was no monitoring to ensure safe storage of cold food.



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